Deborah Meuse Acupuncture
Deborah Meuse, Licensed Acupuncturist
Name ________________________________________ Date of Birth: ______________
Address: ________________________________________________________________
City, State, Zip: __________________________________________________________
Telephone: Home: ________________________ Work: __________________________
Cell: ___________________ Email address: ___________________________________
Occupation: _____________________________________________________________
Primary Care Physician: ___________________________________________________
Emergency Contact: __________________________ Telephone : __________________
How did you hear about my office? ___________________________________________
What is the main problem you would like to address with acupuncture?
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How long ago did this problem begin? Please be specific if you can.
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How does this problem interfere with your daily activities or lifestyle?
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What other treatments or solutions have you tried?
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Has your primary care physician given you a Western Medical diagnosis?
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Please list any medications you are currently taking and what they are for.
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Please list any vitamins, herbs or supplements you are taking for this or other conditions.
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20 Depot Street, Suite 20-230 Peterborough, NH 03458 603-562-5813
www.northstar-acupuncture.com
Please check off each symptom you have experienced in the past six months:
Head/Face
__ Migraines
__ Frequent headaches
__ Dizzy, fainting
__ Poor memory
__ Head feels cloudy/heavy
__ Facial paralysis
Nose/Throat
__ Allergies
__ Sinus infections
__ Sinus headaches
__ Trouble swallowing
__ Sensation of “lump in throat”
__ Chronic laryngitis
Respiratory
__ Shortness of breath
__ Asthma
__ Chronic bronchitis
__ Cough
__ Emphysema
__ Lung cancer
__ Heaviness in chest
Appetite/Thirst
__ Increased appetite
__ Decreased appetite
__ Crave sweet taste
__ Crave sour taste
__ Crave salty taste
__ Crave bitter taste
__ Crave pungent taste
__ Excess thirst
__ Lack of thirst
Urination
__ Increased frequency
__ Pain or burning
__ Waking to urinate at night
__ Incontinence/leaking
__ Difficulty urinating
__ Frequent infections
__ Kidney stones
Eyes
__Blurring of vision
__ Floaters
__ Watery eyes
__ Dry eyes
__ Itchy, irritated eyes
__ Loss of vision
Skin/Hair
__ Psoriasis
__ Eczema
__ Hives
__ Other rash
__ Dryness
__ Recent thinning hair
Cardiovascular
__ Pain in chest
__ Tightness in chest
__ Heart palpitations
__ Irregular heart rhythm
__ High blood pressure
__ High cholesterol
__ Hardening of arteries
Digestion
__ Heartburn
__ Chronic gas
__ Nausea
__ Vomiting
__ Abdominal pain
__ Cramping
__ Gall stones
__ Food allergies
Ears
__ Ringing in ears
__ Loss of hearing
__ Ear Infections
__ Congestion
__ Dizziness: vertigo
Muscles & Joints
__ Arthritis in ______
__ Bursitis in _______
__ Tendonitis in _____
__ Twitching muscles
__ Stiff/tight muscles
__ Sciatica/low back pain
__ Neck pain
Sleep
__ Hard to fall asleep
__ Hard to stay asleep
__ Nightmares
__ Snoring
__ “Restless legs”
Body Temperature
__ Always cold
__ Always hot
__ Cold hands & feet
__ Sweating at night
__ Sweating too much
__ Sweating too little
Energy Level
__ Fatigue
__ Heavy Limbs
__ Feeling sleepy
__ Difficulty walking
__ Too much energy
__ Restlessness
__ Waking up tired
Stools
__ Diarrhea
__ Constipation
__ Irritable bowel
__ Blood in stool
__ Mucus in stool
__ Colitis
__ Hemorrhoids
__ Parasites
OB/GYN
Fertility
Other symptoms
__ Irregular periods
__ Miscarriage
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__ Heavy periods
__ Stillbirth
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__ Light periods
__ # Pregnancies
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__ PMS
__ # Children
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__ Cramping
__ # Abortions
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__ Endometriosis
__ Irregular ovulation
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__ Ovarian Cysts
__ Other information
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__ Uterine fibroids
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__ Sexually transmitted disease
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Mental Health
__ Anxiety
__ Panic attacks
__ Depression
__ Bipolar disorder
__ Phobias
__ Other
__ Seasonal affective disorder
Please rate the degree to which the following emotions are problematic for you:
__ Grief & Sadness
Not at all
Sometimes
Frequently
__ Excitement & Mania
Not at all
Sometimes
Frequently
__ Anger & Frustration
Not at all
Sometimes
Frequently
__ Fear & Dread
Not at all
Sometimes
Frequently
__ Worry & Excess thinking Not at all
Sometimes
Frequently
Family History: Is there anyone in your immediate family with:
__ Cancer
__ Heart disease
__ Diabetes
__ Stroke
__ Allergies
__ Seizures
__ Other inherited conditions_____________________________________________________
Please list history of surgeries, hospitalizations and other medical conditions:
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Lifestyle questions:
How much coffee, tea, or cola do you drink per week? _________________________________
How much alcohol do you drink per week? __________________________________________
How many packs of cigarettes do you smoke per week? _______________________________
Do you have a regular exercise program? __________________________________________
Are there additional problems you hope to discuss with me or address with acupuncture?
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